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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT I 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 7 YEAR FROM DATE ISSUED If Complete In Triplicate} ` Application is hereby made to the San Jaquin Local Health District far a r° made in compliance with San Joaquin County Ordinance No.549 for sewage or Na. 1862 for well �r r 1; � ' permit to construct and/or install the work herein described. This application is Local Health District. � ,, � .y � - /Pump and the Ryles and Regulations of the San Joaquin Job Address City ^ Lot Size 5 Owner's Name PM ! Address f Phohej. 1111 Contractor Address/ 7 -� TYPE OF WELL/PUMPNEW WELL ❑ icense No. WPhone ¢ PUMP INSTALLATION ❑ ELL REPLACEMENT ❑ DESTRUCTION C1 ._ DISTANCE TO NEAREST: SEPTIC TANK SYSTEM REPAIR WT" OTHER ❑ J -� SEWER LAVES .,�� DISPOSAL FLD. i FOUNDATION AGRICULTURE WELL PROP. LINE INTENDED USE TYPE OF WELL PROBLEM AREA OTHER WELL PITS/SUMPS CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ~ ll E ❑ Domestic/Private Manteca Dia. of Wexcavation ❑ Gravel Pack ❑ Tracy T Dia. Of Weil Casing El Irrigation ❑ Public C1 Other �. Type of Casing . LDDelta Depth of Grout Seal Specifications ---Approx. De th Type of Grout Repair Work Done $ T Eastern Surface Seal Installed by Type i Pump H.P. F Well Destruction ❑ Well Diameter�� State ork Done Depth Sealing Material (top 50')r�`TYPE OFiller Material (Below 50') F SEPTIC WORK: NEW INSTALLATION 777 REPAIR/ ITIOL) FDESTRUCT rve: ADDN ._ - : , _-S . oma - ION EI (No septic system permitted if public sewer is Installation will seResidenceCommercial Other . available within 200 feet.) Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: SEPTIC TANK ❑ Type/Mfg ,V Water table depth PKG. TREATMENT PLT. ❑ Capacity-. No. Compartments `Distance to nearest:-: .� Method of Disposal :I �. r Foundation_ Property Line LEACHING LINE 1° f 'F ❑ �Na:& Length of lines FILTER BED ❑ Distance to nearest: Well -1 Total ellTotal length/size .;Foundation I Property Line (l SEEPAGE PITSDepth ❑ � Size SUMPS ❑ Distance-to-nearest:.- _ _Well Number DISPOSAL PONDS ❑ F� Foundation_ Property.Line_ _ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the following: 1 employ any person in such manner as to become subject to workman's kman's certify compensation laws Of California."Contractots hiring or sub contracting signature n the Performance of the work for which this permit is issued, I shall not certifies the following:"I certify that in the performance of the work for which this ermit is issued,I shall employ tion laws of California." p t P Y Pers-.Ys S+d1?l ct To-"man's compensa- � The applican must call required inspections. Complete drawing on r rseide. r Signed +r Title: t`r# jDate: fQ FOR DEPART ENT USE ONLY Application Accepted by - t / Date �ld z` 4, Pit or Grout Inspection by _. N�Q�:� Area ._.. Date Final Inspection by Additional Comments: e �. ti. „ D Stk 466-6781 t`" Lodi 369-36'11 t ❑ anteca 823-7104 ❑ Tracy 835-6385 �.:Y Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Sik.,~CA 95201 �. FEE INFO AMOUNT DUE, jAM1OUNT REMIT CASH RECEIVED BY DATE PERMIT"No. EH13241REV.tie51 i * EH 1426 . _ .�. . �. / ice. � --►.��